EHR Training | EMR and EHR

Balancing EHR Change vs Train

I was talking with Heather Haugen from The Breakaway Group (A Xerox company) today and in our discussion she used the word “train”, but I heard the word “change”. I always love a good play on words and so it was interesting for me to consider the difference between change and train in an EHR implementation.

Every EHR implementation I’ve been apart of walks a fine line between users wanting the EHR software to change versus the need for an EHR user to change. One of the most common phrases out of a doctor’s mouth during an EHR implementation is, “Why did the EHR vendor implement that feature like this? Did they not talk to a doctor? This makes no sense.” We’ve dug in previously to the concept of EHR vendors consulting doctors during their EHR development so we won’t go into that further now. Every EHR vendor consults doctors, but no two doctors practice alike. So, it’s normal that every doctor would wonder why certain features are implemented the way they are implemented.

When faced with this issue, the doctor is faced with an important decision with two options. The first option is to work with the EHR vendor and convince them to change how their EHR works. In a large hospital EHR vendor situation, this can be almost impossible. Plus, even if that EHR vendor does like your suggested change it’s going to take months and sometimes years before that change is implemented in the EHR software, tested, and released all the way to you the end user. Yes, these changes can go faster with a SaaS EHR, but it still will likely take months before the change reaches the end user.

In some cases, you can wait for the change to be made before using that EHR feature. However, more often than not a doctor is going to have to train on how the EHR vendor has implemented the feature. This highlights to me why having great EHR training is so important. Sure, many of the things in an EHR will be intuitive, but great EHR training is still always beneficial. EHR software is too complex to just pickup and use. Plus, even if you can use the basic EHR features, good training points out the ways to optimize the EHR workflow.

Most doctors don’t understand why various parts of an EHR workflow can’t be easily changed. They just think change should happen easily. Ironically, the doctor then proceeds to resist any change to how they want to work.

What Really Differentiates EHR Companies?

My post yesterday on EMR and HIPAA called “Does Spending More on EHR Mean You Get More?” started me thinking what does differentiate one EHR company from another. I think there’s a real disconnect between what most people selecting an EHR use to differentiate EHR companies with what really matters to the users of an EHR.

First let’s take a look at some of the many ways that I see doctors and hospital CIO’s using to differentiate EHR companies. Many use price as an indicator of quality. Hopefully this post puts that to bed. Price matters, but it’s not a great indicator of EHR success. Many are swayed by great sales and marketing by EHR companies. It’s hard to deny that seeing an EHR vendor with a full HIMSS booth doesn’t have some effect on what you think of that EHR vendor. Going along with this is having the big, well branded name recognition. Although, what’s in a name if the EHR software doesn’t meet your specific needs?

Another differentiator that many use is KLAS or other ratings. When I’ve dug into all of the various EHR rating and ranking systems, there are flaws in all of them. Some lack enough data to really draw conclusions. Some use bias methods for collecting data. Some EHR ranking services don’t use data at all. It’s amazing how interested we get in a list that may or may not have any legitimate value. Every EHR vendor has some flashy numbers to share with you. Just remember that numbers can lie. You can make them appear any way you want.

I’m a little torn on the idea of EHR certification and access to EHR incentive money being a point of differentiation for EHR vendors. There are so few that can’t get you there, that it’s almost a non-issue. Sure, if you really want to get the EHR incentive money, you could and should talk to the users of that EHR that have gotten the EHR incentive money. However, because almost every EHR vendor is a certified EHR that can get you to meaningful use, not being certified might actually be a more exciting. The story is reasonable: our EHR focused on what doctors care about in an EHR as opposed to some random government requirements. Could be a compelling message. Especially for those doctors who don’t qualify for the EHR incentive money.

What should be used to differentiate EHR companies?

The number one thing that I think doctors should look for in an EHR is efficiency. A large part of the coming Physician EHR revolt is due EHR software’s impact on physician efficiency. Yet, most doctors selecting an EHR pay little attention to the effect of an EHR on efficiency. This data is harder to get, but a good survey of existing EHR users can usually get you some good information in this regard.

Another area of differentiation with EHR companies should be around their EHR support and training. How quickly an EHR vendor answers support requests and how well an EHR gets you up and running on an EHR is extremely important. As someone on LinkedIn mentioned today, EHR is not plug-n-play software. There’s more to an EHR implementation than just plugging it in and going. It requires some configuration and learning in order to use an EHR in the most effective way.

How come we don’t use the quality of care that an EHR provides as a method of differentiating EHRs? The answer is probably because it’s a really hard thing to measure. I wonder if any EHR has found a way to show that their EHR provides better care. There’s plenty of anecdotal examples, but I wonder if anyone has more data on this.

Another point of differentiation that I think matters is how an EHR company approaches its relationship with the users. Does the doctor, practice and hospital feel like a partner of the EHR company or are they a distant customer. You can imagine which situation is better than the other. This relationship will matter deeply as you run into problems that are unique to your environment. I assure you that this problems will come.

I also see technology approach as a really important factor for EHR companies. When I say this, I think most people start to think about SaaS EHR vs Client Server EHR. Certainly that is one major component to this idea, but it should go much deeper. You can tell by the way an EHR’s technology approach if they’re focused on the right things. Do they take shortcuts when they implement technology? Are they thoughtful about what really matters to the EHR user? Do they implement something on a whim or do they think deeply about the impact of a feature? While every EHR company has limits on what they can put out in a release, they can still provide a great roadmap of the current release and their plans for future releases which shows that they understand the needs of the users.

I’m sure there are many more good ways to differentiate an EHR company. I look forward to hearing more of them in the comments. We just need to expand the discussion to things that really matter as opposed to basing our EHR decisions on vanity metrics.

Cutting EMR Training Budget Can Create Serious Problems

Not long ago, American Medical News ran an article on training up medical practice staffers for EMR use. The piece concluded that while practices may save some bucks on the front end, they generally end up regretting it later. An anecdote from the piece:

Nine months after All Island Gastroenterology and Liver Associates in Malverne, N.Y., went live with its electronic medical record system, practice administrator Michaela Faella realized things had not gone as smoothly as planned.

Even though the staff had used other health information technology systems for many years and considered itself tech-savvy, it had taken everyone six months to learn how to use the new EMR system. Several months later, the staff still had not become proficient at it.

The problem was not with the staff, but that the practice cut training short to save time and money. “Training was not placed high on the priority list, and we paid the price for it,” Faella said.

As the piece notes, many practices assume that the training bundled into the cost of their new EMR will meet their needs, and find out to their regret that this isn’t the case. (In fact, I’d argue that this is more the rule than the exception, based on anecdotes I hear in the field and in conversations with physicians.)

A consultant quoted in the piece suggests that practices should consider three main issues when planning for training:

1) How much data they’ll be dealing with, which can vary greatly depending on whether all data is imported in advance or done patient by patient

2) Whether the practice will be integrating new systems into the EMR, such as e-prescribing, or conversely, adding an EMR to existing systems

3) Whether using the EMR will call for using new hardware such as tablet computers

Personally, I’m not satisfied by that list at all.

What about, first and foremost, assessing the staff’s existing skills more precisely, walking staffers through the various layers of the EMR on a daily basis, forming teams of superusers within the organization to help the less skilled and taking steps to be sure EMR problems don’t interrupt critical functions (a backup/workaround plan for the short term)?

What do you think? Does the list above cover the critical EMR practice integration issues? Am I just being testy?

101 Tips to Make Your EMR and EHR More Useful – EHR Tips 1-5

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I can’t believe that this is the last post in the series. I think it’s been a good series chalk full of good tips for those looking at implementing an EHR in their office. I’d love to hear what people thought and if they’d like me to do more series like this one. Now for the final 5 EMR tips.

5. Automatic trending helps all over the place – A picture is worth a thousand words and this is never more true than when we’re talking about trending. Make sure your EHR software can quickly take a set of results and/or data points and graph them over time.

4. Keep training over and over – Are you ever done learning software? The answer for those using an EMR is no. Part of this has to do with the vast volume of options that are available in EMR software. However, the training doesn’t necessarily have to come from formal training sessions. Much of the training can also come by facilitating interaction and discussion about how your users use the software. By talking to each other, they can often learn from their peers better ways to use the software.

3. Infrastructure is key to performance – I love when people say “My EMR is Slow” cause it’s such a general statement that could have so many possible meanings. Regardless of the cause of slowness, the EMR is going to get the blame. For those wanting to dig in to the EMR slowness issue, you can read my pretty comprehensive post about causes of EMR slowness. I think you’ll also enjoy some of the responses to that EMR slowness post.

Infrastructure really matters when someone is using an EMR all day every day. There’s no better way to kill someone’s desire to use an EMR than to have it be slow (regardless of who’s responsible).

2. Quit pulling charts as soon as possible – I think this tip should be done with some caution. In certain specialties the past chart history matters much more than in others. Although, it’s worth carefully considering how often you really look through the past paper chart in a visit. You might be surprised how rare it is that you really need the past paper chart. If that’s the case, consider only pulling the chart when it’s needed. If you only find yourself looking through the past paper chart for 2 or 3 key items, then just have someone get those 2 or 3 items put into the EMR ahead of time. Then, it will save you having to switch back and forth. Plus, then it’s there for the next time the patient visits.

1. Crap process + Technology = Fast Crap – Perfect way to end 101 EMR and EHR Tips! I like to describe technology as the great magnifier. The challenge is that it will magnify both the good and bad elements of your processes. Fix the process before you apply the technology.

If you want to see my analysis of the other 101 EMR and EHR tips, you can find them all at the following link: 101 EMR and EHR tips analysis.

No EHR Training Needed

Anne Zieger over on EHR Outlook just posted an article talking about the need of training on an EHR. In the article, she quotes Dr. Bertman, CEO of EMR company Amazing Charts (Full Disclosure: They’re a sponsor of this site). Here’s one excerpt from the article:

According to Dr Jonathan Bertman, if you need extensive training to use an EHR, you shouldn’t buy it. “Doctors know how to be doctors,” he says. “They shouldn’t have to be trained to be software technicians – if they need training than it’s not a good thing.”

Here was my response in the comments of the article (and a little additional commentary for this post):
I have a feeling Dr. Bertman and I agree about training, but I think it’s over the top for him to say, “if they need training than it’s not a good thing.” Certainly many EHR software vendors require far too much training. I think that’s the point he’s trying to make and I agree 100%. However, the reality is that there are a whole lot of people that get training even on Office. In fact, there’s a whole entire industry around training on Office products. So, EHR is going to have training as well.

Another excerpt from the article:

“Compare them to Microsoft Office,” Dr. Bertman suggests. “It’s a powerful tool, but you usually don’t need special training to use it. An EHR is not more complicated than Office, and that’s how we should be looking at them.”

I’d generally disagree that an EHR is not more complicated than Office. The reality is that what you want to do in an EHR is more complicated than Office. Sure, if all I want to do is type a little bit and maybe click bold, then I’m fine. Most EHR you don’t need any training to login, browse their appointment grid, browse patients, and even create notes.

The reason for the EHR training that’s out there isn’t for these simple features. It’s for the more advanced features like is done in most Office trainings. I could be wrong, but I believe Dr. Bertman generally agrees with me on this, but it wasn’t expressed in a short quote from him.

One other interesting point is that I think a lot of people call it EHR training when in fact it’s about EHR workflow planning and training. You’re a brave person to implement an EHR without planning out your current workflows and how they’ll map to an EHR workflow. I often see this workflow planning and training covered under the broad definition of EHR training.

101 Tips to Make Your EMR and EHR More Useful – EHR Tips 96-101

Shawn Riley on HealthTechnica has collected a great list called 101 Tips to Make your EMR and EHR More Useful. I find lists like this really interesting and provide a great point of conversation. So, I’m planning to take the 101 ways, and over 10 or so blog posts, I’m going to cover each suggestion and where appropriate provide some commentary on the tip. I expect it will drive some really interesting conversation.

101. Trust, but verify
This is a fine suggestion. It’s a tough balance to achieve, because you want and need to have the trust of your EHR vendor, because once you’re ready to implement that EHR you’re likely going to ask them for help. Some of the help will be rather easy for them to support, but more often than not you might want to ask them for some pretty custom work to make the EHR work the way you want it to work for your clinic. So, you want to make sure that you have a good relationship with your EHR vendor.

However, that doesn’t mean there’s anything wrong with verifying what the EHR vendor and their salespeople are telling you. In fact, it would be a huge mistake not to verify. There are lots of open forums like this website where you can ask and verify a lot of what the EHR representatives are telling you. Also, visit other hospitals, healthcare centers, doctors etc. who have implemented an EHR from the same vendor.

100. Ask about the learning curve
Great suggestion! Although, I don’t think there’s much value asking the EHR vendor about the learning curve. Ok, maybe you can find a little value if you ask them on average how much training their users require to implement their EHR. However, the learning curve of an EHR goes far beyond the initial training. So, you should ask your EHR vendors existing users about the learning curve. Also, try to ask those doctors who have implemented in the last 3-6 months. It’s easy to forget how hard (or easy) it was to learn something when you did it a few years ago.

99. Ask what platforms are supported
Yes, most EMR software is very specific. You can actually find much of the breakout of which platforms various EHR companies support on this EHR and EMR Operating System Compatibility wiki page. Obviously, if you love your Apple products, then you’re going to need to be sure that your EHR platform supports it. Not to mention, the platforms an EHR vendor supports (or more likely doesn’t support) might be a sign of how well the EHR is at keeping up with the latest technological trends.

98. Look for long life and long term support
Switching EMRs is worse than implementing one in the first place. Sure, they usually go better than the initial implementation, but there’s nothing fun about switching EMR software. So, do what you can to ensure that the EHR that you choose is going to be around into the future. Otherwise, even if you don’t want to switch EHR software, you may be forced to do so. It’s not fun redesigning clinical processes for a new EHR.

97. How will your teams be educated on the EMR / EHR?
Yes, your whole team will need to be educated. Even if you have one person that’s educated on all the components and then trains the rest of your staff, each staff member is going to need training. There are even many EHR companies that offer unlimited training. It’s part of their sales pitch. Basically, they offer unlimited training as a way to show that they have to make the EHR really easy to use so that they don’t spend all their time training you.

Personally, I also like to do some up front training for the EHR implementation and then budget for some training a few weeks or a month down the road. You’ll be amazed how much more you learn and how much better questions you ask after having used the EHR for a few weeks or month.

96. Ensure audit logs are easy to get to and are comprehensive
I like to do this best by imagining 5 legal scenarios that you might need the EMR audit logs. Then, ask the EHR vendor to provide you the audit logs for those 5 scenarios so that you can see how it would look if you happen to need that information. This is even better if you can test drive the EHR software and try running the logs yourself.

There you have it. My commentary on the first 5 of 101 EMR and EHR tips. 10 more posts to go. If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other 95.

Top Three Annoying Things EHR Vendors Do To Sell

The following is my personal list of pet peeves about the way vendors conduct themselves during the sales process. This comes from observation, not direct experience, as I’m a researcher rather than a techie — but I hear about these issues over and over.

Top Three Annoying Things EHR Vendors Do To Sell
(in no particular order):

1. Can’t explain how their product actually solves physician problems: Tech companies can’t help being a little, er, technical when they describe their products, and EHR firms are no exception. Too often, they end up writing their documentation to please their colleagues rather than their customers. Others, meanwhile, entice customers with shallow nonsense (oh, and I mention spectacular, $200K boothes at HIMSS) then throw a confusing technical mess at buyers when they’re ready to look closer.

2. Claim their product is a Swiss Army knife: Even the biggest, baddest enterprise EHR package will eventually need significant add-ons such as master data management technology. Not only that, implementing any high-end EHR product will call for bridging technologies that integrate everything from labs to PACS.

3. Slack off on support after the sale: Oh, this is a classic one for just about any software vendor, but it’s particularly damaging where EHRs are concerned. Vendors often overpromise and under-deliver when it comes to tech support. The wise IT manager will evaluate what they need in the way of training and support, then make sure they get absolutely everything on the list.

I’ll be interested to see if you disagree with these, or come up with others. Just shoot me a note at katherine@emrandehr.com.

Providers Aren’t Taking EMR Training Seriously Enough

As we noted in a previous post, the latest group of EMR buyers have gotten savvy about support. As a new study suggests, more than ever, providers are choosing vendors who offer a great deal of handholding. And that’s probably a good idea, according to Michael Patmas of the American College of Healthcare Executives. Below, here’s some of his thoughts on EMR and CPOE project failures.

I have had the unfortunate experience of being in two organizations that had EMR and / or CPOE implementation failures as well as one organization that was successful. A key learning for me was the need to adequately fund training and support. Too often, implementation plans are driven by the vendor who tend to under emphasize the training needs. Simply providing a few hours of hands on training for the physicians is not enough. The real training begins after one flips the switch and providers have to actually work with the system in real time during clinical encounters. That’s when having trainers available to sit with and coach the providers is essential. In every implementation failure I have seen, the organizations under-invested in training and ongoing support.

Sadly, though, many providers seem to cross their fingers and hope a little training will somehow diffuse automatically into the organization. This is a dangerously irresponsible stance, but it’s all too common.

In fact, at three separate community hospitals, I’ve personally witnessed doctors and nurses huddled together over an EMR workstation trying to teach each other how to use the system. If it made me squirm — under these circumstances, serious errors like misdocumenting drug allergies are all but inevitable — hospital leaders should be terrified, shouldn’t they?

New APN’s View of EMR

Today I got the following message (actually on Facebook) from a previous colleague of mine. When I worked with her she was an RN, but she just finished her education to become an APN and found a job at a local well known medical provider. Here’e her message to me after starting the job (specific names removed):

Help! I need to learn [Jabba the Hutt EMR's] charting system;-( No bueno… Mucho hard!! I like [previous job's] EMR so much better!!

Excuse the spanglish and almost text message style feel to the message. In fact, I wouldn’t be surprised if she sent me that Facebook message from her phone. Yes, our methods of communicating are changing.

I was pretty taken a back by her message actually. Not because I haven’t heard complaints about this Jabba the Hutt EMR system (Definition of Jabba the Hutt EMR Vendors: Good in their day, but have gotten so big and bulky that they’re barely functional) before. I actually had heard similar stories, but I just didn’t expect it from her. She was always very good at computers and doing what she needed to do with the EMR when I worked with her. Plus, she’d already used a couple different EMR in her career.

I will discount part of her reaction as the knee jerk response to a new job, a new company, APN instead of RN and a new EMR software. That’s a pretty steep learning curve for anyone.

The challenge this comment provides however is how do clinics train new doctors on their EMR. In my opinion, the real problem for my friend isn’t like the EMR software, but is instead the training that she received on the EMR software. Properly trained, I’m sure she’d like using the EMR software a lot more than she just expressed.

Training new staff on the EMR is a challenge and vitally important. I was in charge of training the new staff at my previous work. I trained everyone from medical records staff to Lab Tech’s to MA’s to RN’s to APN’s to PA’s to MD’s and DO’s. I trained general medicine providers, dietitians, GYN’s, dermatologists, and a few other specialists. That’s a wide variety of people to train, but overall we did a pretty good job with most. Outside of our initial implementation where the whole staff was trained, I probably trained 50 different people. Let’s just say that people definitely learn at different paces.

About 2 minutes into the training I could tell you how good (or bad) the training was going to go. I could train a provider on our EMR system in about 45 minutes to an hour to the point that they’d feel comfortable doing their job. Certainly there were some intricacies to looking up various codes and charges, but generally they knew what they were doing after an hour. The worst case scenarios usually ended up needing about 2 hours of training where I had a little more time to let them flounder through the charting process themselves on our test install so that they could really learn in a low pressure environment.

In our case, we had a contract with an outside company where they were always swapping out providers. Luckily our nursing staff was very consistent and could assist the new providers as various questions popped up.

To be honest, I think this system of training worked pretty well. One of the keys to our success was that we had a well defined process for using the EMR. So, a technical person like myself could easily train a clinical provider. Plus, I was deliberate in only showing them the easiest route to chart (at first) even though there was almost always 3-4 ways to do something. I learned this lesson the hard way. Far too many people get confused when you train them on 3 ways to do the same thing.

My favorite story about training a doctor though was when a doctor was ill and so a replacement doctor was provided from the company we partnered with. Turns out the new doctor they sent was pretty tech savvy and confident (not to be confused with arrogant). We looked at the clock and realized him and I would only have 5-10 minutes to train him on the EMR system. This was far from ideal, but you make the most of whatever situations come. So, I cranked through the most important features and processes. Then, I wished him good luck! He had a great day with no issues. Of course, as I said above, we had a nursing staff that could assist him as needed as well.

Moral to the Story: As a clinic it’s important to have a way to train new staff on your EMR.

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Balancing EHR Change vs Train

What Really Differentiates EHR Companies?

Cutting EMR Training Budget Can Create Serious Problems

No EHR Training Needed

101 Tips to Make Your EMR and EHR More Useful – EHR Tips 96-101

Top Three Annoying Things EHR Vendors Do To Sell

Providers Aren’t Taking EMR Training Seriously Enough

New APN’s View of EMR

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